Ferpa Consent To Release Student Information Form
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1ferpa consent to release student information
The Family Education Rights and Privacy Act of 1974 (FERPA) states that a student must authorize in writing
the release of his/her educational records. Please complete and sign this form to authorize release of your
educational records.
please provide information from the education records of:
__________________________________________________________________________________________________________
student’s name – print
to: _______________________________________________________________________________________________________
name(s) of requestor
__________________________________________________________________________________________________________
relationship to the student such as “parent,” “spouse,” “prospective employer,” or “attorney”
__________________________________________________________________________________________________________
password/code (select an identifier to provide requestor) or agency or company tax id number of requestor
Note: This consent does not cover medical records held solely by Student Health Services or University
Counseling Services. Contact those offices for consent forms.
student declaration:
i understand the information may be released orally or in the form of copies of written records, as preferred by the requestor.
i understand that this form remains in effect until otherwise revoked by me.
student name (print) _______________________________________________________________________________________
student signature __________________________________________________________________________________________
student id number _________________________________________________________________________________________
academic Year ________________________________________________________ date ________________________________
notary signature ___________________________________________________________________________________________
form must be notarized if not delivered in person by student.
send form to appropriate office.
Virginia commonwealth university
Office of Financial Aid • P.O. Box 843026 • Richmond, VA 23284
Office of Records and Registration • P.O. Box 842520 • Richmond, VA 23284
Student Accounting Department • P.O. Box 843036 • Richmond, VA 23284
Virginia Commonwealth University
Office of Records & Registration
Division of Student Affairs & Enrollment Services
P.O. Box 842520 • Richmond, VA 23284-2520
an Equal Opportunity/Affirmative Action university
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